Nigeria’s seven lessons from polio and Ebola response

Amid the devastating effects of West Africa’s Ebola outbreak to human lives, communities, institutions, systems and the economy, there are lessons to be learned for the region to be better prepared to handle future outbreaks.

Granted, the Ebola outbreak in Nigeria was caught early before it spiralled out of control, unlike in Sierra Leone, Liberia and Guinea, but Nigeria was also able to successfully contain the disease. The country would have not been able to respond so swiftly if it had not had a history of responding to public health emergencies, such as recurrent cholera and Lassa fever outbreaks and lead poisoning, and developed an appropriate response capacity.

Some components of the Ebola response in Nigeria were adapted from the country’s polio eradication efforts, as well as infrastructure and capacity built in response to an Avian Flu outbreak in 2006. Until recently, polio had debilitated thousands of Nigerian children annually. In 2015, Nigeria marked the one-year anniversary of Wild Polio Virus interruption, and had before been declared Ebola-free.

So we ask: How did a previously weak system suddenly gain the momentum to operate efficiently and yield favorable outcomes? Are there lessons we can learn related to the effectiveness of future disease surveillance and emergency response efforts? In both instances [Ebola and polio], we found an alignment of several factors – what we call the seven “P’s:”

Politics of Purpose– Political leaders in Nigeria made eradication of both polio and Ebola national priorities. This established a clarity of purpose and focus. It enabled cooperation across political and technical cadres, federal and state institutions, and across public and private sectors. While technical managers had a mandate to roll out the response, there was still consistent accountability to political leaders (via national task forces, and even the President). We all had a stake in it.

Providing the Right Platform- The Polio Emergency Operations Centre (EOC) and its vast experience and resources served as a springboard for the country’s Ebola response. The center operated an Incident Command System, which involved a plethora of actors, including government and donors, but bypassed bureaucracies. The EOC was therefore quick to make decisions and respond, as well as use real-time data and intense reviews to increase efficiency.

Aligning People with Processes – The EOC structures have routine operational cycles. In the Ebola response, data was reviewed in real-time, and operations were reviewed every 12 hours. All roles within the EOC were clearly defined, allowing individuals to be held accountable for specific results during reviews. Actions were tracked by team managers who had a degree of autonomy to make decisions, be it to reallocate resources or to enforce strict adherence to contact tracing protocols. In the case of polio, poor-performing health workers were removed from their positions and replaced with more efficient workers.

Proactive Public Engagement – Both polio immunization efforts and the Ebola response were beset by myths and rumors, which caused more harm than good and spread like wildfire. With socio-cultural beliefs often at opposite poles to public health messages, misinformation not only hampers adequate preventive action, but can lead to fatalities, as with the case of drinking salt water for Ebola prevention. But, as the responses unfolded, communication with the public and communities improved in clarity and consistency, thus building trust and enhancing cooperation.

Prolific Partnerships - Bringing a range of actors from within the public and private sectors, including the donor communities, onto a singular platform allowed for more efficient use of resources. It also permitted a good mix of international and local technical expertise while balancing contextual realities. The multi-sectoral approach also enabled response teams to harness the best resources and capabilities from non-traditional players in the health sector. For instance, the provision of SIM cards and Internet data plans provided by telecommunications companies went a long way to enable real-time contact tracing and reporting.

Pioneering Alternative Pathways – When human resources could not be mobilized from health facilities for case management, the EOC team had to think of an alternative recruitment strategy. By mobilizing workers on an individual (contract) basis and creating an incentive package for their engagement, the EOC team was able to pull together a crop of willing and motivated health workers to work at the frontlines. Similarly, after initially using paper-based forms, the use of GPS-tracked handheld devices ensured that contact tracing teams reported accurately from the specified location during each of the 18, 000 household visits made. The polio response also navigated areas affected by insurgency by using different community entry strategies such as “firewalling” or “hit and run,” where community engagement was layered to canvas the entire region or timed to minimize risk of exposure.

Priming the System – Nigeria was largely unprepared to mount a response to polio, however, in areas where prior investments had been made, such as with the Nigeria Field Epidemiology Training Program, which provided an army of frontline health workers trained in surveillance to carry out contact tracing.

For Nigeria, investments made in the Polio Emergency Operations Centre present a great opportunity. This platform has proven its worth in its ability to morph and mobilize rapidly into a public health emergency response system that delivers results, even outside its original mandate. Extending the center’s legacy could include creation of decentralized EOCs in each state, to incorporate the health, animal and environmental sectors in a bid to achieve the “One Health” goal. The lessons we have learned about health systems, public institutions and their capacity to deliver must be well-documented and brought to bear in future planning. We look back to move forward.

While some say that the world is still largely unprepared for another Ebola outbreak, the lessons from the Ebola and polio responses can be valuable in the drive towards a “One Health” system and integrated regional approach to disease surveillance. In West African countries, there is no doubt that preparedness must take a form heavy on resources and light on bureaucracy to mount an effective outbreak response.

Regional surveillance will only be as strong as the sum of its individual country systems and one weak system can compromise the strength of others. This means that the work begins at country level and the institutions, each system working from within, for the sake of all. A proposed World Bank-financed Regional Disease Surveillance System Enhancement Project (REDISSE) for Western Africa is coming at the right time and will provide necessary support and resources towards building a robust and resilient surveillance system in the region.

Comments

The very specific lessons of the Nigeria success story need to be more broadly disseminated, specifically the preparedness of the Public Health approach targeted at pandemics and fully addressing the communication and adaptive behavior issues.

The cost effectiveness of the Nigeria response ($13 million), and the large number of people mobilized in a short period (200 physicians and 600 other health workers)could also be more widely appreciated.

Many thanks Wole and colleagues for a great and insightful blog. The Nigeria experience with Ebola is a good example of the value of adopting a diagonal approach to build health systems--that is, how the setting of explicit intervention priorities such as Polio eradication can help drive required changes and improvements into the health system. Contrary to the false dichotomy between vertical programs and health system development often argued by some observers and international officials, disease eradication programs such as Polio in Nigeria have indeed led to the strengthening of health infrastructures without undermining or at the expense of broader health system development efforts. Both type of efforts are part of the same coin and complement each other!!! The evidence from the Nigeria experience is clear: as you argue in the blog, part of the reason Nigeria was able to contain Ebola in 2015 was that polio workers and systems were deployed on time and used to help with the response. Evidence for policy making!!!!

Really great post! The key lessons are clearly articulated with the critical points and learning as well as evidence available demonstrating how coordinated efforts led to the control of health emergencies. An expectation is to have these learning's used to galvanize governments and other stakeholders to action against diseases such as lassa fever.